Removal of biofilm is essential for long-term ventilation tube retention

BACKGROUND Although long-term retention of a ventilation tube is required in many ear diseases,spontaneous removal of conventional ventilation tube is observed in patients within 3 to 12 mo.To address this issue,we aimed to determine a new method for long-term retention of the ventilation tube.AIM To explore the value of removing the biofilm for long-term retention of tympanostomy ventilation tubes.METHODS A case-control study design was used to evaluate the safety and effectiveness of long-term tube retention by directly removing the biofilm(via surgical exfoliation)in patients who underwent myringotomy with ventilation tube placement.The patients were randomly divided into two groups:Control group and treatment group.Patients in the treatment group underwent regular biofilm exfoliation surgery in the clinic,whereas those in the control group did not have their biofilm removed.Only conventional ventilation tubes were placed in this study.Outcome measures were tube position and patency.Tube retention time and any complications were documented.RESULTS Eight patients with biofilm removal and eight patients without biofilm removal as a control group were enrolled in the study.The tympanostomy tube retention time was significantly longer in the treatment group(43.5±26.4 mo)than in the control group(9.5±6.9 mo)(P=0.003).More tympanostomy tubes were found to be patent and in correct position in the treatment group during the follow-up intervals than in the control group(P=0.01).CONCLUSION Despite the use of short-term ventilation tubes,direct biofilm removal can be a well-tolerated and effective treatment for long-term tube retention of tympanostomy ventilation tubes in patients who underwent myringotomy.     

Evaluation of diaphragmatic dysfunction after surgical treatment of type A aortic dissection by ultrasound: Incidence,risk factors and influence on outcomes北大核心CSCD

Objective: To study the incidence, possible risk factors, and influence on patient outcomes of diaphragmatic dysfunction in patients after surgical treatment of type A aortic dissection using ultrasound. Methods: Patients who received replacement of hemiarch or total arch with concomitant procedures concerning aortic pathology, and an elephant trunk procedure for the descending aorta were prospectively enrolled in this study from February to May 2017. After surgery, they were transferred to the cardiac surgical intensive care unit. They were divided into two groups based on diaphragmatic excursion: diaphragmatic dysfunction (DD) group and diaphragmatic function normal (DN) grouBilateral diaphragmatic excursions were evaluated using ultrasound during spontaneous breathing trial by T-tube. The differences in demographic characteristics, operation-related variables and outcomes were compared between the two groups. Results: A total of 42 patients were enrolled in this study, and 32 of them suffered from diaphragmatic dysfunctions. Compared with DN group, the excursion of the influenced diaphragm in DD group was significantly reduced[(0.450 ± 0.331)cm vs. (1.801 ± 0.616)cm, P<0.01], while the excursion of the non-influenced diaphragm was not reduced[(2.013±0.655)cm vs. (1.801±0.616) cm, P=0.254]. Diaphragmatic thickness was comparable [(0.184±0.028)cm vs. (0.189±0.028)cm, P=0.559] between the two groups while thickening fraction was significantly reduced in DD group[(4.67%±3.63)% vs. (23.58%±10.69)%, P<0.01]. Meanwhile, respiratory rate was significantly higher in DD group as compared to DN group [(24.13 ± 4.98)times/min vs. (20.50 ± 3.17)times/min, P=0.037]. Patients in DD group showed longer cross-clamp duration[(121.78±27.75)min vs. (93.10±18.84)min, P=0.004] and longer cardiopulmonary bypass duration [(208.09±32.78)min vs. (182.70±24.38)min, P=0.03] than patients in DN grouFurthermore, binary logistic analysis indicated that longer cross-clamp duration was the potential risk factor for diaphragmatic dysfunction after type A aortic dissection surgery. Mechanical ventilation duration was longer in DD group than in DN group (88 h vs. 37 h, P=0.194) but without statistical significance. The usage of noninvasive ventilation was significantly increased in DD group as compared to DN group (46.88% vs. 10%, P=0.036). Other outcomes such as post-operative complications, mortality, ICU length of stay were comparable between the two groups. Conclusions: Diaphragmatic dysfunction was very common after surgical treatment of type A aortic dissection. Longer duration of cross-clamp was considered as a potential risk factor of diaphragmatic dysfunction. A sequential management of noninvasive ventilation after extubation was feasible for diaphragmatic dysfunction after surgical treatment of type A aortic dissection. © 2018 Chinese Medical Association. All rights reserved.     

正压机械通气与膈肌起搏联合通气对呼吸衰竭患者呼吸力学的影响

目的 观察正压机械通气与膈肌起搏联合通气对呼吸衰竭(呼衰)患者呼吸力学的影响.方法 采用自身前后对照研究方法,以20例中枢性呼衰患者先使用常规正压机械通气30 min作为对照组,后改用正压机械通气与膈肌起搏联合通气30 min作为试验组,观察两种通气方式下患者的呼吸力学变化.结果 与对照组比较,试验组平均气道压(Paw,cm H2O,1 cm H2O=0.098 kPa)、平台压(Pplat,cm H2O)明显降低(Paw:6.1±1.3比7.3±1.8;Pplat:10.4±2.5比12.1±2.6,均P＜0.05),峰食道压力(PPEAK ES,cm H2O)、峰食道压力与基准食道压力差(dPES,cm H2O)负值明显增加(PPEAK ES:-8.3±1.9比-3.2±1.4;dPES:-11.2±2.6比-8.2±2.2,均P＜0.05),吸气末屏气期间的跨肺压(Ptp plat,cm H2O)、呼吸系统静态顺应性(Cst,ml/cm H2O)明显增加(Ptp plat:23.6±3.8比15.6±3.1 Cst:52.7±8.2比48.3±7.2,均P＜0.05),气道阻力(Raw,cm H2O·L-1·s-1)、肺部阻力(RL,cm H2O·L-1·s-1)无明显改变(Raw:2.1±0.5比2.3±0.4; RL:2.9±0.6比3.1±0.5,均P＞0.05),患者呼吸功(WOBp,J/L)明显增加、机械呼吸功(WOBv,J/L)明显降低(WOBp:0.18±0.03比0;WOBv:0.31±0.07比0.53±0.11,均P＜0.05).结论 正压机械通气与膈肌起搏联合通气进行呼吸支持可明显降低呼衰患者气道压力,增加胸腔内压负值和跨肺压,提高肺顺应性,并能降低机械通气作功,但对气道阻力无明显影响.

Abstract：

Objective To observe the effects of combining positive pressure ventilation with diaphragm pacing on respiratory mechanics in patients with respiratory failure. Methods Twenty patients with central respiratory failure were studied with cohorts. The effects on respiratory mechanics were respectively observed in patients in control group, in whom ventilation by positive pressure only, and patients in experimental group in whom ventilation was instituted by combining positive pressure ventilation with diaphragm pacing. Results Compared with control group, mean airway pressure (Paw, cm H2O,1 cm H2O= 0. 098 kPa) and plateau pressure (Pplat, cm H2O) were significantly decreased in experimental group (Paw: 6. 1±1.3 vs. 7. 3±1.8; Pplat: 10. 4±2.5 vs. 12. 1±2. 6, both P＜0. 05), while the nagative value of peak esophageal pressure (PPEAK ES, cm H2O), the nagative value of the difference between peak and basic esophageal pressure (dPES, cm H2O), transpulmonary pressure at end of inspiration hold (Ptp plat,cm H2O), static compliance (Cst, ml/cm H2O) were significantly increased in experimental group (PPEAKES:-8.3±1.9 vs. -3.2±1.4; dPES: -11.2±2.6 vs. -8. 2±2. 2; Ptp plat: 23.6±3.8 vs. 15.6±3.1; Cst:52. 7±8. 2 vs. 48. 3 ±7. 2, all P ＜ 0. 05 ). No differences were found in airway resistance (Raw,cm H2O · L-1 · s-1) and lung resistance (RL, cm H2O · L-1 · s-1) between experimental group and control group (Raw: 2.1±0.5 vs. 2.3±0.4; RL: 2.9±0.6 vs. 3.1±0.5, both P＞0.05). Work of breath by patient (WOBp, J/L) was significantly increased and work of breath by ventilator (WOBv, J/L) was significantly decreased in experimental group compared with control group (WOBp: 0. 18± 0. 03 vs. 0;WOBv: 0.31±0.07 vs. 0.53±0.11, both P＜0.05). Conclusion Compared with positive pressure ventilation, positive pressure ventilation combined with diaphragm pacing can decrease the Paw, increase intrathoracic negative pressure, transpulmonary pressure, and Cst, and decrease WOBv, while there is no effect on Raw and RL.     

Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND: This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insuffi ciency(CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD).METHODS: Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit(ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group(n=32) and a control group(n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone(150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers ofinfl ammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value 0.05 was considered statistically signifi cant.RESULTS: Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4%. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI(23.8% vs. 8.7%, P0.01). KaplanMeier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group(P0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group(18.2±9.5 vs. 25.8±4.1, P0.05). Treatment with low-dose glucocorticoid obviously decreased the markers ofinfection and inflammation(P0.01), such as C-reactive protein(13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α(26.1±16.2 g/L vs. 17.5±11.7 g/L for the control group; 25.0±14.8 g/L vs. 10.4±7.8 g/L for the treatment group) and procalcitonin(3.88 g/L vs. 2.03 g/L for the control group; 3.77 g/L vs. 1.26 g/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group(P0.01).CONCLUSION: The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers ofinfection and infl ammation.     

床边纤维支气管镜在呼吸衰竭机械通气患者中的应用及护理

目的 探讨纤维支气管镜(简称纤支镜)在呼吸衰竭机械通气患者中应用的临床意义及护理干预.方法 将64例呼吸衰竭机械通气的患者随机分为对照组和治疗组各32例.2组患者均给予全身抗感染、雾化吸入等对症支持治疗及相应护理.治疗组予床边纤支镜肺泡灌洗治疗,对照组常规吸痰治疗.分析比较2组治疗前后的症状、体征及血气分析变化情况.结果 2组的有效率、治愈率比较差异显著;治疗组血气变化、肺部感染控制窗时间、机械通气时间及平均住院时间优于对照组;治疗组成功撤机、器官衰竭及院内死亡例数显著低于对照组.结论 呼吸衰竭机械通气患者行纤支镜肺泡灌洗可改善通气和预后,是安全、有效的.护理干预对提高纤支镜吸痰及灌洗术的成功率起到了不可忽视的重要作用,达到良好的治疗及护理效果.

Abstract：

Objective To investigate the application and nursing care of bronchoalveolar lavage (BAL)by fiberoptic bronchoscopy in patients with mechanical ventilation. Methods 64 patients with mechanical ventilation in RICU were randomly divided into the control group and the observation group with 32 patients in each group. The patients in both groups were accepted anti-infection, atomization inhalation and other supportive treatments. The patients in the observation group were treated with BAL, and the patients in the control group accepted routine treatment. The therapeutic effects in the two groups were evaluated and compared. Results There was significant difference in the recovery rate and effective rate, the blood gas analysis compared with the control group was significantly improved, the time of pulmonary infection control window, mechanical ventilation, length of stay were shorter than the control group. The case number to remove ventilator successfully, organs failure and hospital mortality were less than the control group. Conclusions Fiberoptic bronchoscopy with BAL treatment could be safety and efficacy for patients with mechanical ventilation. Nursing intervention plays an important role and a good therapeutic effect for improving achievement ratio of BAL.     

临床护理路径在ARDS患者机械通气中的效果评价

目的 探讨临床护理路径(clinical nursing pathway,CNP)护理模式在ARDS机械通气中的应用效果.方法 选择2008年6月至2010年12月入住ICU的59例实施机械通气的ARDS患者,随机分为观察组30例和对照组29例,对照组采用传统的整体护理模式,按常规进行机械通气的监测、治疗和护理;观察组按制订好的临床护理路径进行护理.比较2组患者呼吸机应用时间、机械通气并发症发生率、患者及家属满意度等指标.结果 观察组患者呼吸机应用时间少于对照组,机械通气并发症发生率低于对照组,患者及家属满意度优于对照组.结论 临床护理路径用于ARDS机械通气中,能缩短机械通气时间,降低机械通气并发症发生率,提高患者及家属对护理工作的满意度.

Abstract：

Objective To investigate the effect of clinical nursing pathway on mechanical ventilation effect of ARDS patients. Methods 59 ARDS patients with mechanical ventilation from June 2008 to December 2010 were randomly divided into the observation group (30 cases)and the control group (29 cases). The control group used the traditional care model, conventional mechanical ventilation monitoring,treatment and care according to routine measures; the observation group used clinical nursing pathway. The mechanical ventilation time, complication rate of mechanical ventilation, and the gratification level of patients in the two groups of patients were observed. Results The mechanical ventilation time in the observation group was less than the control group, and incidence of complications was lower, and satisfaction degree of patients and their families was better, the difference was statistically significant. Conclusions The clinical nursing pathway can shorten the time of mechanical ventilation, lower incidence of complications of mechanical ventilation, and it improves satisfaction degree of patients and their families.     

E-flow显像评价系统性硬化病患者指端微循环变化

目的 探讨高频超声结合E-flow显像评价系统性硬化病(systemic sclerosis,SSc)患者指端微循环病变的临床价值.方法 SSc患者 24 例,正常对照组 29 例,均行高频超声检查并结合E-flow显像,观察各组受试者左右手中指末节指端血管分布特征、走行,测量指掌侧固有动脉、指腹动脉及甲床动脉收缩期峰值流速(PSV)、舒张末期流速(EDV)、平均血流速度(MV)、阻力指数(RI)及搏动指数(PI).结果 对照组末节指端血流信号丰富,可清晰显示指掌侧固有动脉、指腹动脉、甲床动脉及其细小分支;SSc末节指端血流显示欠清晰,连续性欠佳,血流分布明显减少.与对照组相比,SSc组中指末端指掌侧固有动脉、指腹动脉及甲床动脉PSV、EDV、MV均减低(P＜0.01),而RI及PI增高(P＜0.05).对照组左右侧指端动脉血流参数无明显差异(P＞0.05),而SSc组左侧指掌侧固有动脉PSV、EDV及MV指标较右侧增高,差异均有统计学意义(P＜0.05).结论 高频超声结合E-flow显像可敏感、准确地反映SSc患者的指端微循环变化,为临床评价SSc患者微血管病变情况提供了新方法.

Abstract：

Objective To investigate the clinical value of high frequency ultrasonography with E-flow imaging in the evaluation of fingertip's microcirculation changes in patients with systemic sclerosis(SSc).Methods Twenty-four SSc patients and 29 healthy subjects were involved.High frequency ultrasonography with E-flow imaging was used to observe the configuration and distribution of digital arteries in the last segment of left and right middle finger.Peak systolic velocity (PSV),end diastolic velocity (EDV),mean velocity(MV),vascular resistance index (RI) and pulsatility index(PI) of digital palmar propria arteries,nail bed arteries and finger ventral arteries were measured.Results In control group,rich blood supply was revealed within the fingertips.Digital palmar propria arteries,nail bed arteries and finger ventral arteries and their small branches were displayed clearly and continuously by E-flow imaging.While in SSc patients,the definition and continuity of fingertip's small vascular flow images were not as good as that in the control group,with the distribution of blood flow markedly reduced.compared with the control group,PSV,EDV and MV of digital palmar propria arteries,nail bed arteries,finger ventral arteries were decreased in SSc group(P＜0.01),but both RI and PI were increased(P＜0.05).There were no statistically significant differences between left and right fingertip's arteries index in normal control group (P＞0.05).But PSV,EDV and MV of left digital palmar propria arteries in SSc group were higher than that of the right(P＜0.05),whose differences bear statistic significance.Conclusions High frequency ultrasonography with E-flow imaging is sensitive and reliable to reflect fingertip's microcirculation changes and provide a new method to assess microvascular changes in SSc patients.     

无创正压通气对急性呼吸衰竭患者拔管后再插管率和预后影响的荟萃分析

Objective To evaluate the effects of noninvasive positive pressure ventilation (NPPV)used after extubation on mortality and rate of reintubation in patients with acute respiratory failure (ARF).Method Pubmed, Embase, Web of Science databases were searched to collect data from randomized controlled trials (RCT) of the relevant subject from January 1995 to May 2010. Meta analysis of data about NPPV on mortality and rate of reintubation in patients after extubation carried out by using the methods recommended by the Cochrane Collaboration. Results Six RCTs included sample size of 381 NPPV and 379routine medical care. In total, the mortalities of patients in NPPV group and routine medical care group were 18.6% (62/334) vs. 21.6% (72/333), respectively, and the rates of reintubation of the two groups were 30.2% (115/381) vs. 33.5% (127/379), respectively. Compared with routine medical care, NPPV did not significantly reduce the mortality ( OR: 0.83, 95% CI =0.57 ～ 1.21 ,P =0.34) and rate of reintuation( OR: 0.83, 95% CI = 0.59 ～ 1.16, ( P = 0.27). When the analysis was focused to the four studies of them in which patients received NPPV as soon as extubation, the results were quite different. From these four studies, the mortalities of patients in NPPV group and routine medical care group were 12. 2% (22/181) vs.23.9% (44/184),(P=0.004), and the rate of reintubation of the two groups were 14.0% (32/228) vs.20.4% (47/230), (P =0.07). Compared with routine medical care, early application of NPPV to patients after extubation reduced the mortality. Conclusions This study suggests the favorable effects of early application of NPPV to patients after extubation on the mortality of acute respiratory failure.     

持续脑电双频指数监测对急性脑损伤患者预后的评估

目的 探讨持续脑电双频指数(BIS)监测对急性脑损伤患者预后的评估作用.方法 采用回顾性研究方法,选择2009年3月至2010年7月重症监护病房(ICU)急性脑损伤昏迷患者61例,根据预后将患者分为生存组(25例)和死亡组(36例).于入ICU 3 d内或停用镇静剂24 h后持续12 h监测BIS,取其均值(BISmean)、记录BIS最大值(BISmax)和最小值(BISmin).记算患者急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分、存活概率(PS)、格拉斯哥昏迷评分(GCS),并于监测当日取静脉血检测S100蛋白、神经元特异性烯醇化酶(NSE)水平;分析BISmean与GCS评分、$100蛋白、NSE水平的相关性.结果 ①两组患者性别、年龄、机械通气时间无明显差异.死亡组APACHE Ⅱ评分(分)明显高于生存组(27.36±5.99比23.28±6.69),PS明显低于生存组(0.31±0.17比0.49±0.19),住ICU时间(d)明显短于生存组(6.33±4.48比27.88±54.46),P<0.05或P<0.01.②死亡组BISmean、BISmax、BISmin、GCS均明显低于生存组(BISmean:35.45±28.31比55.91±17.53,BISmax:51.92±34.24比74.84±16.58,BISmin:22.39±24.83比39.68±15.72,GCS评分(分):3.64±1.19比5.60±2.22],P<0.05或P<0.01;血清S100蛋白、NSE水平明显高于生存组[S100蛋白(μg/L):7.54±10.49比1.18±1.57,NSE(μg/L):120.74±109.01比49.83±54.94],均P<0.01.③双变量相关分析显示,BISmean与GCS评分呈显著正相关(r=0.379,P=0.003),与S100蛋白、NSE水平呈显著负相关(r1=-0.418,P1=0.001;r2=-0.290,P2=0.023).结论 BIS监测具有无创、直观、易于操作、可连续监测的特点,可以作为判断急性脑损伤患者预后的早期客观指标.

Abstract：

Objective To discuss the effect of continuous monitoring of bispectral index(BIS)on the prognosis of patients with acute brain injury.Methods A retrospective study was carried out,61 patients with acute brain injury admitted to the intensive care unit (ICU) from March 2009 to July 201 0 were divided into survival group (n=25) and death group (n=36).The BIS was continuously monitored for 12 hours within the first 3 days or 24 hours after stoppage of sedative after admission to ICU.The mean value of BIS (BISmean),the maximal value of BIS(BISmax),and the minimal value of BIS(BISmin)were evaluated.At the same time,the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,probability of survival (PS) and Glasgow coma score (GCS) were evaluated.The values of serum S100 protein and neuron-specific enolase (NSE) were determined.The relationship between BISmean and GCS,S100 protein and NSE were respectively analyzed.Results ①There was no significant difference in the sex,age,or duration of mechanical ventilation between two groups.APACHE Ⅱ score in death group was significantly higher than the survival group (27.36±5.99 vs.23.28±6.69),PS was significantly lower than the survival group(0.31±0.17 vs.0.49±0.19),and length of stay in ICU (days) was significantly lower than that of the survival group(6.33±4.48 vs.27.88±54.46),P<0.05 or P<0.01.②BISmean,BISmax,BISmin,GCS in death group were significantly lower than those in the survival group (BISmean:35.45±28.31 vs.55.91±17.53,BISmax:51.92±34.24 vs.74.84±1 6.58,BISmin:22.39±24.83 vs.39.68±15.72,GCS score:3.64±1.19 vs.5.60±2.22),P<0.05 or P<0.01,while serum S100 protein and NSE levels were significantly higher than the survival group(S100 protein(μg/L):7.54±10.49 vs.1.18±1.57,NSE (μg/L):120.74±109.01 vs.49.83±54.94],both P<0.01.③By bivariate analysis,BISmean was positively correlated with GCS(r=0.379,P=0.003),whereas it was found to be negatively correlated with S100 protein and NSE levels(r1=-0.418,P1=0.001;r2=-0.290,P2=0.023).Conclusion BIS monitoring can be applied as an early objective indicator to evaluate the prognosis of the acute brain injured patients with the characteristics of being noninvasive,intuitive,easy-to-manipulate,and non-stop monitoring.     

Body mass index and COVID-19 outcomes:A retrospective cross-sectional study at a tertiary care center in India

Objective:To determine the association between body weight and COVID-19 outcomes.Methods:This is a retrospective cohort study of COVID-19 patients admitted in a dedicated COVID-19 hospital,a tertiary health care center,between May and June 2021.Demographic data and baseline variables,including age,sex,body mass index(BMI),and comorbidities were collected.Outcomes(death or mechanical ventilation)of the patients with different BMI,age,comorbidities,and qSOFA scores were compared.Besides,the risk factors for death or mechanical ventilation were determined.Results:The mean age of the subjects was(51.8±14.7)years old,and 233(74.2%)were male.There were 103(32.8%)patients with normal weight,143(45.5%)patients were overweight,and 68(21.7%)patients were obese.In-hospital deaths and need of mechanical ventilations were significantly higher in the obese and the overweight group compared to the normal weight group,in age group≥65 years compared to<65 years,in patients with≥1 comorbidities compared to patients without comorbidities,in patients with qSOFA scores≥2 compared to patients with qSOFA scores<2.There was a significantly increased risk of death(RR:4.1,95%CI 1.0-17.4,P=0.04)and significantly increased need of mechanical ventilation(RR:5.2,95%CI 1.8-15.2,P=0.002)in the obese patients compared with those with normal weight after controlling other covariates.Conclusion:Obesity is one of the significant risk factors for adverse outcomes in COVID-19 patients and should be considered during management.     

有创-无创序贯性机械通气治疗老年肺内源性急性呼吸窘迫综合征随机对照临床研究

目的 评价有创-无创序贯性机械通气治疗老年肺内源性急性呼吸窘迫综合征(ARDS)患者的疗效及可行性.方法 32例老年肺内源性ARDS患者被随机分为序贯治疗组及常规治疗对照组,每组16例.两组均建立人工气道,以辅助/控制模式+呼气末正压(PEEP)+间隙性控制性肺膨胀(SI)方式通气24 h,随病情改善改用同步间歇指令通气(SIMV)+压力支持通气(PSV)+PEEP的方式.待"ARDS控制窗"出现,序贯组改换为无创正压通气(NIPPV),以持续气道正压(CPAP)方式通气并逐渐脱离呼吸机;对照组以SIMV+PSV+PEEP常规方式脱机.动态观察两组患者的通气及氧合指标,记录有创和总机械通气时间、呼吸机相关性肺炎(VAP)发生情况及住呼吸重症监护病房(RICU)的天数.结果 两组患者治疗前血气分析结果相仿(P均>0.05);序贯组有创通气时间[(4.6±1.0)d]、总机械通气时间[(12.7±4.0)d]、住RICU时间[(16±7)d]较对照组[分别为(21.9±9.0)d、(21.9±9.0)d、(29±13)d]明显缩短,VAP发生率[6.25%(1/16)]和病死率[25.00%(4/16)]也较对照组[分别为75.00%(12/16)、56.25%(9/16)]明显降低,差异均有统计学意义(P<0.05或P<0.01).结论 对老年肺内源性ARDS插管机械通气以ARDS控制窗为时机及时改用无创通气可显著改善其疗效.     

SIMV加PSV／PSV切换结合高碳酸血症治疗慢性阻塞性肺疾病呼吸衰竭的临床研究

目的探讨同步间歇强制通气加压力支持通气／压力支持通气两种模式切换结合允许性高碳酸血症（PHC）技术治疗慢性阻塞性肺疾病急性呼吸衰竭的可行性和安全性。方法30例接受气管插管和机械通气的慢性阻塞性肺疾病（COPD）急性呼吸衰竭病例随机分为两组，各15例。研究组（A组）予小潮气量（7ml／kg）机械通气并实施PHC技术，对照组（B组）予常规潮气量（12ml／kg）机械通气。观察两组潮气量（VT）、分钟通气量（MV）、气道峰压（Ppeak）、平台压（Pplat）、动脉血气变化、机械通气时间、住院时间、呼吸机相关性肺炎（VAP）例数和气胸例数。结果治疗后2h、24hA组气道峰压Ppeak、平台压Pplat低于B组（P〈0．01）；机械通气2h、24hA组pn、Pa02值上升，PaC02值下降的速度滞后于B组，但与机械通气前比较，P〈0．05或P〈0．01；A、B两组机械通气时间为（7．2±3．2）d和（15．6±10．6）d，p〈0．01；住院时间为（10．2±3．2）d和（18．6±10．4）d，P〈0．05；发生呼吸机相关性肺炎2例和8例（p=0．022）；气胸0例和4例（p=0．049）。结论SIMV＋PSV／PSV切换联合PHC技术治疗慢性阻塞性肺疾病急性呼吸衰竭可以缩短机械通气时间和住院时间，降低机械通气的VAP发生率和气压伤风险。     

无创通气在慢性阻塞性肺疾病并呼吸衰竭患者撤机中的应用

目的探讨无创通气(NIV)在慢性阻塞性肺疾病急性加重(AECOPD)并呼吸衰竭中作为撤机方式的应用价值。方法接受气管插管有创通气的38例AECOPD并呼吸衰竭患者在病情有所好转,但尚未完全达到拔管撤机标准时随机分为两组:NIV组:拔管后立即经面罩给予NIV进行过渡撤机;有创正压通气(IPPV)组:继续经气管导管给予压力支持通气(PSV)实施过渡撤机。观察两组患者的动脉血气变化、机械通气时间、住院时间、再插管率和病死率。结果拔管后应用NIV患者的pH,PaCO2和PaO2与应用IPPV患者无明显差异(P>0.05)。NIV组患者VAP的发生率明显低于IPPV组(P<0.05),NIV组的有创通气时间和住院时间明显短于IPPV组(P<0.05),病死率低于IPPV组(P<0.05)。结论应用NIV作为正在接受有创通气治疗的AECOPD并呼吸衰竭患者的撤机方式是可行的,NIV可降低VAP的发生率,缩短有创通气时间和住院时间,降低病死率。     

双相气道正压通气在慢性阻塞性肺疾病患者有创机械通气撤机中的应用

目的探讨双相气道正压通气在慢性阻塞性肺疾病（COPD）重度Ⅱ型呼吸衰竭撤机中的应用价值。方法COPD呼吸衰竭行有创机械通气患者41例,随机分为治疗组2l例与对照组20例。出现肺部感染控制窗时治疗组拔除气管内导管,应用BiPAP通气方式行无创通气,对照组按照常规方法逐步撤机。主要观测指标为：有创通气时间、机械通气总时间、撤机成功率、呼吸机相关肺炎（VAP）发生率和院内病死率。结果出现肺部感染控制窗时两组资料相比差异均无统计学意义（P均〉0．05）。治疗组拔管时与应用双相气道正压通气2h相比,心率、呼吸、动脉血气差异均无统计学意义（P均〉0．05）。治疗组的有创通气时间较对照组缩短[（6．9±3．0）d与（13．1±4．3）dt=5．38,P〈0．01];VAP发生率较对照组降低[48％（1／21）与40％（8／20）],X^2=5．51,P=0．02],撤机成功率较对照组提高[95％（20／21）与65％（13／20）,X^2=4．19,P=0．04]。但两组机械通气总时间、院内病死率相比差异均无统计学意义（P均〉0．05）。结论当COPD上机患者出现肺部感染控制窗时,应用双相气道正压通气方式撤机可缩短有创通气时间、降低VAP发生率、提高撤机成功率。     

自主呼吸试验在撤机中的应用

目的 对应用自主呼吸试验(SBT)撤机方式与逐渐降低机械通气支持水平撤机方式成功拔管的患者进行比较,以寻找最佳撤机方式.方法 选择57例机械通气患者,病情稳定后通过撤机试验前评估,然后准备撤机.采用前后对照的方法将患者分为两组,2004年6月-2005年12月的21例患者作为对照组,采用逐渐降低机械通气支持水平的撤机方式拔管;2006年1月-2007年3月的36例患者作用为试验组,采用SBT的撤机方式拔管.分别观察两组患者的机械通气时间、住重症监护病房(ICU)时间、呼吸机相关性肺炎(VAP)发生率、48 h内再插管率、ICU病死率.结果 试验组与对照组的机械通气时间分别为(59.45±37.1)h和(111.4±59.8)h(P=0.001),住ICU时间分别为(8.0±5.5)d和(15.3±14.3)d(P=0.034),VAP发生率分别为16.7%和38.0%(P=0.070),48 h内再插管率分别为19.4%和5.0%(P=0.253),ICU病死率分别为25.0%和24.0%(P=0.920).结论 SBT的撤机方式比逐渐降低机械通气支持水平的撤机方式具有机械通气时间和住ICU时间短的优点,而两组VAP发生率、48 h内再插管率、ICU病死率基本相同.     

慢性阻塞性肺疾病患者机械通气时间的影响因素

目的 探讨影响慢性阻塞性肺疾病(COPD)患者机械通气(MV)时间的危险因素.方法 回顾性研究128例COPD合并呼吸衰竭患者插管前及通气过程中的临床指标.单凶素分析采用t检验、秩和检验及X2检验.将统计意义的变量导人多元逐步togis～e回归分析.结果 NV>7 d、14 d和21 d的患者比例分别为61%、20%和9%.MV>7 d、14 d和21 d的患者,分别与MV≤7 d、14 d和21 d的患者进行比较,在COPD病史、吸烟指数、肺功能和合并症等方面差异无统计学意义(P<0.05).多因素回归分析显示,APACHEⅡ评分是影响MV>7 d的独立危险因子(OR:2.3;95%CI:1.2～5.7,P=0.02);影响MV>21 d的危险因素是休克(OR:0.7;95%CI:1.0～1.9,P=0.04)和低白蛋白水平(OR:0.4,95%CI:0.2～0.8,P=0.003);机械通气相关性肺炎(VAP)是影响机械通气时间最重要的危险因素(P<0.05).结论 APACHEⅡ评分、血清白蛋白水平、发生休克或VAP是影响COPD患者机械通气时间的主要因素.     

Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing

Objective Evidence that PS may facilitate weaning from mechanical ventilation (MV), although not confirmed by randomized trials, prompted us to investigate whether patients could be weaned with PS after failing a T-tube trial.Design and setting This was a prospective, non-randomized study in two French intensive care units.Patients and participants One hundred eighteen patients were enrolled and underwent a T-tube trial, after which 87 were extubated. Thirty-one underwent a further trial with PS, after which 21 were extubated.Interventions All patients under MV >24 h meeting the criteria for a weaning test underwent a 30-min T-tube trial. If this was successful, they were immediately extubated. Otherwise, a 30-min trial with +7 cm H₂O PS was initiated with an individualized pressurization slope and trigger adjustment. If all weaning criteria were met, the patients were extubated; otherwise, MV was reinstated.Measurements and Results The extubation failure rate at 48 h did not differ significantly between the groups: 11/87 (13%) versus 4/21 (19%), P=0.39. The groups were comparable with regard to endotracheal tube diameter, MV duration, the use of non-invasive ventilation (NIV) after extubation, initial severity score, age and underlying pathology, except for COPD. A significantly higher percentage of patients with COPD was extubated after the trial with PS (8/21–38%) than after a single T-tube trial (11/87–13%) (P=0.003).Conclusions Of the patients, 21/118 (18%) could be extubated after a trial with PS, despite having failed a T-tube trial. The reintubation rate was not increased. This protocol may particularly benefit patients who are most difficult to wean, notably those with COPD.     

纤维支气管镜在慢性阻塞性肺疾病机械通气序贯撤机中的应用

目的 观察应用纤维支气管镜(纤支镜)辅助慢性阻塞性肺疾病急性发作(AECOPD)并发呼吸衰竭患者机械通气时序贯撤机的临床疗效.方法 将106例AECOPD并发呼吸衰竭接受经口气管插管和机械通气者随机分为2组:应用纤支镜辅助有创-无创机械通气序贯撤机组(A组,54例)和有创-无创机械通气序贯撤机组(B组,52例).A组纤支镜从气管导管外进入气道,操作过程中不间断使用呼吸机.两组患者一般治疗相同,达肺部感染控制窗( PIC)后拔除气管导管改无创机械通气模式,然后依情况决定撤机.治疗后比较两组病例下列指标:(1)PIC出现时间、总机械通气时间、住ICU时间、首次撤机成功率、再上机率、呼吸机相关肺炎(VAP)发生率;(2)纤支镜操作对该类患者的安全性.结果 A组和B组PIC出现时间分别为(5.01±1.49)d、(5.87±1.87)d,p＜0.05;总机械通气时间分别为(6.98±1.84)d、(8.69±2.41)d,P＜0.01;住ICU时间分别为(9.25±1.84)d、(11.10±2.63)d,P＜0.01;首次撤机成功率分别为96.30％、76.92％,P＜0.01;再上机率分别为5.56％、19.23％,P＜0.05;VAP发生率分别为3.70％、23.07％,P＜0.01.治疗组纤支镜操作简便、安全,未发生明显不良反应.结论 AECOPD并发呼吸衰竭进行机械通气患者应用纤支镜辅助治疗可缩短机械通气时间,增加撤机成功率,减少VAP的发生,且方便安全.     

平均容积保证压力支持模式无创通气对超重的慢性阻塞性肺疾病患者急性Ⅱ型呼吸衰竭的治疗研究

目的 比较无创双水平正压通气（BiPAP）平均容积保证压力支持（AVAPS）模式与同步/时间控制（S/T）模式在肥胖的慢性阻塞性肺疾病（COPD）患者并发急性Ⅱ型呼吸衰竭中的治疗作用。 方法 选取2012年3月－2013年6月入院治疗且体质量指数（BMI）＞25 kg/m2的COPD发生急性Ⅱ型呼吸衰竭患者36例,按数字随机表法分为AVAPS组与S/T组。两组的基础治疗相同,AVAPS组采用飞利浦伟康V60呼吸机BiPAP AVAPS模式进行无创通气治疗,S/T组采用相同机型BiPAP S/T模式治疗。分别比较两组患者治疗1、6、24、72 h的格拉斯高昏迷（GCS）评分变化、血气分析结果、呼吸机监测数据。 结果 AVAPS组患者在最初治疗的6 h内GCS评分高于S/T组[1 h：（13.2 ± 0.6）、（11.9 ± 0.6） 分,P＜0.05;6 h：（13.8 ± 0.5）、（12.1 ± 0.6）分,P＜0.05];24 h内的动脉血气酸碱度pH值改善[1 h：7.31 ± 0.03、7.26 ± 0.02,P＜0.05;6 h：7.37 ± 0.05、7.31 ± 0.04,P＜0.05];24 h：7.40 ± 0.04、7.33 ± 0.03,P＜0.05]及二氧化碳分压下降[1 h：（65.2 ± 5.1）、（69.5 ± 4.1）mm Hg（1 mm Hg=0.133 kPa）,P＜0.05;6 h：（61.4 ± 4.2）、（66.7 ± 4.3） mm Hg,P＜0.05;24 h：（58.2 ± 4.5）、（64.3 ± 5.4） mm Hg,P＜0.05）]优于S/T组,24 h内浅快呼吸指数低于S/T组[1 h：（35.2 ± 8.1）、（62.8 ± 13.2）次/（min·L）,P＜0.05];6 h（33.4 ± 7.8） 、（54.8 ± 11.6）次/（min·L）,P＜0.05],同时,减少了额外的人工参数调整次数[3.4 ± 1.1、1.2 ± 0.6）,P＜0.05] 结论 对超重的COPD合并急性Ⅱ型呼吸衰竭患者采用AVAPS模式进行无创通气治疗,较S/T模式能更快地恢复意识水平,更快地降低血二氧化碳分压、改善pH值,同时减少了呼吸治疗师的人工操作次数。     

Clinical consequences of the implementation of a weaning protocol

Objective To analyze the clinical and economic consequences of the implementation of a weaning protocol in patients mechanically ventilated (MV) for more than 48 h.Design Comparative studySetting General intensive care unit (ICU) in a county hospital covering 360 000 inhabitants.Patients 51 patients weaned by a fixed protocol were studied prospectively and compared with 50 retrospective controls.Measurements The following variables were assessed: Acute Physiology and Chronic Health Evaluation (APACHE) II score, age, cause of respiratory failure, type of extubation (direct extubation or extubation using a weaning technique), number of days on MV before the weaning trial, weaning time, total duration of MV, complications (reintubations and tracheostomies), length of ICU stay, and mortality.Results The groups were comparble in terms of age, APACHE II score, and main cause of acute respiratory failure. Number of days on MV up to the weaning trial were similar in the two groups (8.4±7.7 in the protocol group vs 7.5±5.5 in the control group, NS). Most of the patients (80%) in the protocol group were directly extubated without a weaning technique, unlike the control group (10%) (p<0.01). When a weaning technique was used, the weaning time was similar in both groups (3.5±3.9 days vs 3.6±2.2 days in the control group). Duration of MV was shorter in the protocol group (10.4±11.6 days) than in the control group (14.4±10.3 days) (p<0.05). As a result, the ICU stay was reduced by using the weaning protocol (16.7±16.5 days vs 20.3±13.2 days in the control group,p<0.05). We found no differences in reintubation rate (17 vs 14% in the control group) and need for tracheostomies (2 vs 8% in the control group).Conclusion The implementation of a weaning protocol decreased the duration of MV and ICU stay by increasing the number of safe, direct extubations.Supported in part by grant FIS 93/0590